Hyperkalemia in pediatric chronic kidney disease

Background: While hyperkalemia is well described in adult chronic kidney disease (CKD), large studies evaluating potassium trends and risk factors for hyperkalemia in pediatric CKD are lacking. This study aimed to characterize hyperkalemia prevalence and risk factors in pediatric CKD. Methods: Cross-sectional analysis of Chronic Kidney Disease in Children (CKiD) study data evaluated median potassium levels and percentage of visits with hyperkalemia (K ≥5.5 mmoL/L) in relation to demographics, CKD stage, etiology, proteinuria, and acid–base status. Multiple logistic regression was used to identify risk factors for hyperkalemia. Results: One thousand and fifty CKiD participants with 5183 visits were included (mean age 13.1 years, 62.7% male, 32.9% self-identifying as African American or Hispanic). A percentage of 76.6% had non-glomerular disease, 18.7% had CKD stage 4/5, 25.8% had low CO₂, and 54.2% were receiving ACEi/ARB therapy. Unadjusted analysis identified a median serum potassium level of 4.5 mmol/L (IQR 4.1–5.0, p <0.001) and hyperkalemia in 6.6% of participants with CKD stage 4/5. Hyperkalemia was present in 14.3% of visits with CKD stage 4/5 and glomerular disease. Hyperkalemia was associated with low CO₂ (OR 7.72, 95%CI 3.05–19.54), CKD stage 4/5 (OR 9.17, 95%CI 4.02–20.89), and use of ACEi/ARB therapy (OR 2.14, 95%CI 1.36–3.37). Those with non-glomerular disease were less frequently hyperkalemic (OR 0.52, 95%CI 0.34–0.80). Age, sex, and race/ethnicity were not associated with hyperkalemia. Conclusions: Hyperkalemia was observed more frequently in children with advanced stage CKD, glomerular disease, low CO₂, and ACEi/ARB use. These data can help clinicians identify high-risk patients who may benefit from earlier initiation of potassium-lowering therapies. Graphical Abstract: [Figure not available: see fulltext.].